Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program

Applications and efficacy of radically open dialectical behavior therapy (RO DBT): A systematic review of the literature

Radically open dialectical behaviour therapy (RO DBT) is a transdiagnostic treatment, originally developed as a variant of dialectical behaviour therapy (DBT), that emerged as a novel treatment approach for those presenting with excessive or maladaptive overcontrol. Despite RO DBT's growing popularity among clinicians as a treatment for chronic depression, personality disorders and eating disorders, to date, no systematic review has been conducted to summarise the evidence on this therapy. Therefore, the aim of this study was to systematically review the literature to provide a current and comprehensive summary of the available evidence on the clinical applications and efficacy of RO DBT. Articles were included if they were original research studies that described the use of RO DBT in the treatment of any psychological disorder, condition or symptom, published in the English language in a peer-reviewed journal. Four electronic databases were searched, and screening, selection, risk of bias assessment and data extraction were all conducted by two independent reviewers. Fourteen articles were included in this review, including two qualitative articles, one case study, five case series studies, four quasi-experimental studies, and two articles describing one randomized control trial. Findings indicated there is emerging evidence for the use of RO DBT in both adolescents and adults, for disorders characterized by excessive self-control, such as anorexia nervosa and autism, as well as for treatment-resistant depression. While RO DBT shows promise as a treatment for disorders of overcontrol, further research is needed. This review outlines current gaps and identifies areas for future research.

Telehealth-Delivered Radically Open Dialectical Behavior Therapy for Adolescents (RO DBT-A): A Pilot Mixed-Methods Study

OBJECTIVE

Disorders related to overcontrol frequently first appear during adolescence, are highly comorbid, and show limited treatment response, necessitating the adaptation of radically open dialectical behavior therapy (RO DBT; a transdiagnostic treatment targeting overcontrol) for adolescents (RO DBT-A). This study tested the preliminary efficacy of telehealth-delivered RO DBT-A in a heterogeneous clinical sample of youths.

METHODS

The sample consisted of 20 female participants ages 13-21 with elevated overcontrol; most were White (75%) and non-Hispanic/Latino (80%). RO DBT-A was provided over 20 weeks via skills group and individual sessions (N=13 participants). Participants seeking other treatment or no treatment formed the control group (N=7). Outcomes included self-reported symptoms and overcontrol. Follow-up interviews were analyzed by using inductive, contextualist thematic analysis to examine participant perceptions and reasons for dropout.

RESULTS

The RO DBT-A group showed significant improvements in depression (t=-1.78, df=10, p=0.011) and quality of life (QOL; Wilcoxon W=75, p=0.021) compared with the control group. From baseline to posttreatment, youths receiving RO DBT-A demonstrated significant improvements in maladaptive overcontrol (t=2.76, df=12, p=0.043), anxiety (t=2.91, df=12, p=0.043), depression (Wilcoxon signed rank V=82.5, p=0.043), and QOL (t=-3.01, df=12, p=0.043). Qualitative analysis revealed themes related to treatment barriers, facilitators, and timing.

CONCLUSIONS

The findings provide preliminary evidence supporting telehealth-delivered RO DBT-A in targeting overcontrol, decreasing symptomatology, and improving QOL in a heterogeneous clinical sample of youths. Qualitative follow-ups highlighted that dropout was driven by barriers related to therapy (e.g., structure- and therapist-related issues) and the timing of RO DBT-A compared with other treatments.

Investigating the Theory of Clinical Perfectionism in a Transdiagnostic Eating Disorder Sample Using Network Analysis

Eating disorders are deadly psychiatric illnesses, with treatments working for less than half of individuals who seek treatment. The transdiagnostic theory of eating disorders proposes that eating disorders share similar maintaining symptoms, such as what this theory calls clinical perfectionism (i.e., high levels of concern over mistakes and personal standards). However, it has been difficult to examine the interrelationship of specific aspects of perfectionism, beyond assessing moderation effects, which have generally not found support for the theory of clinical perfectionism in eating disorders. Thus, we used network analysis to test the theory of perfectionism by testing the interrelationships between maladaptive perfectionism facets (concern over mistakes, personal standards, parental criticism, parental expectations, and personal standards) and eating disorder symptoms in 397 individuals diagnosed with an eating disorder. Concern over mistakes was a central symptom and demonstrated the strongest interrelationships with eating disorder symptoms compared to the other aspects of perfectionism, connecting to eating concerns and cognitive restraint. Objective binge eating had a strong negative connection to personal standards. We identified specific central symptoms and illness pathways of perfectionism, which partially supports the theory of clinical perfectionism. Results, if replicated, may suggest that concern over mistakes might be best reconceptualized as part of eating disorder pathology and be targeted to improve treatment outcomes for eating disorders.

Emotional reactivity and prosocial behaviour in response to witnessing social exclusion in adolescents with eating disorders and healthy controls

BACKGROUND

Prosocial behaviour can promote positive social interactions and it is a key skill in adolescence. People with emotional problems or psychiatric disorders, such as people with eating disorders might have impairments in prosocial behaviour, due to broader documented difficulties in underlying processes (e.g., mentalizing).

METHODS

The aim of this study was to examine prosocial behaviour in adolescents with eating disorders compared to healthy controls, using a computerised behavioural task. Adolescents (N = 123) including patients with eating disorders (n = 61) and healthy adolescents (n = 62) played a four-player computerised Prosocial Cyberball Game with three pre-programmed avatar players. During the task, participants witnessed the exclusion of one of the players, and subsequently had the opportunity to compensate for this by throwing the ball more often to the excluded player. Throughout the game, participants rated the level of negative emotion in themselves and in the excluded player.

RESULTS

Patients made significantly fewer ball tosses towards the excluded player during the compensation round compared to healthy controls (large effect size). Patients reported a significantly smaller increase in negative emotion after witnessing the exclusion and a significantly smaller decrease in negative emotion following the compensation round (large effect sizes). Patients also estimated a smaller decrease in negative emotion in the excluded player following the compensation round (medium effect size). There were no significant associations between these outcomes and eating disorder psychopathology in patients.

CONCLUSIONS

Compared to healthy adolescents, adolescent patients with eating disorders demonstrated less prosocial compensatory behaviour towards a computerised victim of social exclusion. In addition, they reported flatter negative emotion in themselves in response to witnessing and compensating for exclusion, and in the excluded player following compensation. If these findings are replicated, interventions to target these difficulties might contribute to improvements in social functioning in this patient group.

"Ordinary days would be extraordinary": The lived experiences of severe and enduring anorexia nervosa

OBJECTIVE

Approximately 25% of individuals with anorexia nervosa (AN) experience a chronic form of the disorder, referred to as severe and enduring anorexia nervosa (SE-AN). Although the classification of SE-AN remains preliminary, there have been increasing calls for a harm reduction-based, collaborative treatment model for these patients. To provide such care for patients with SE-AN, it is critical to listen to and learn from their lived experiences.

METHOD

Patients (N = 17) admitted to an inpatient eating disorders program who met initial criteria for SE-AN completed semi-structured interviews about the course of their illness and prior treatment episodes. Interviews were audio recorded and transcribed. Data were analyzed using an inductive, reflexive approach to thematic analysis that examined common themes within and across interviews.

RESULTS

Three themes were identified focused on (1) the all-encompassing nature of SE-AN, (2) treatment experiences, and (3) living with chronic illness. Within these themes, there were subthemes. Overall, individuals noted clear insight about their condition, both negative and positive experiences with previous treatment, and hope for better quality of life despite their illness.

DISCUSSION

Individuals with SE-AN describe their illness as a chronic condition and hope for a harm reduction-based treatment. Future work, including the lived experiences of individuals with SE-AN, is important to build our understanding of the classification and clinical characteristics of SE-AN and to develop treatment approaches that may best serve these individuals.

PUBLIC SIGNIFICANCE

Many people with anorexia nervosa do not achieve a full recovery despite repeated treatment episodes throughout their lifespan. Understanding the lived experiences of individuals with SE-AN may help to inform future treatment development efforts that could improve eating disorder and quality of life outcomes for these patients.

Emotion Regulation Deficits in Adolescent Girls with Major Depression, Anorexia Nervosa and Comorbid Major Depression and Anorexia Nervosa

In adolescence, both major depression (MD) and anorexia nervosa (AN) are associated with deficits in emotion regulation (ER). However, studies have yet to compare ER profiles within the disorders and the effect of comorbid MD+AN is unclear. This study examined the habitual use of ER in 229 girls, aged 12-18 years, with MD (n = 84), AN (n = 37), comorbid MD+AN (n = 25), and healthy girls (n = 83). Girls with MD, AN and MD+AN reported more maladaptive and less adaptive ER strategies than healthy girls. MD and MD+AN groups showed more frequent use of maladaptive ER compared to only AN, with no differences between only MD and MD+AN. This suggests that MD+AN is not necessarily associated with higher ER deficits, rather, an additional diagnosis of MD exacerbates impairments in AN. Identifying specific ER profiles can provide important targets in prevention and treatment for AN, MD and AN+MD.

Social support across eating disorder diagnostic groups: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III)

INTRODUCTION

Previous studies have suggested the positive influence of social support on the treatment and recovery of eating disorders (EDs). Yet, more research is needed on how objective and subjective social support differ between ED diagnostic groups using nationally representative data. Therefore, the current secondary data analysis examined associations between EDs and objective and subjective social support using data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study.

METHODS

Participants completed measures of lifetime and past year diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorder (BED) and items assessing objective social support (i.e., number of close friends and close relatives) and subjective social support (i.e., perceptions of availability of support).

RESULTS

Compared to those without EDs, those with AN, BN, and BED had poorer subjective social support-or lower perceptions of social support. However, there were fewer differences regarding objective social support. Individuals with BN reported a lower number of close relatives compared to those without EDs and those with AN, but there were no differences in the number of close friends between ED groups. Those who experienced remission from EDs had higher perceptions of social support compared to those with past year EDs.

DISCUSSION

The findings show deficits in subjective social support across EDs but only lower objective social support in BN. This highlights the clinical utility of increasing perceptions of social support across EDs. The findings also show the importance of perceived social support in recovery from EDs.

Childhood behavioral inhibition and overcontrol: Relationships with cognitive functioning, error monitoring, anxiety and obsessive-compulsive symptoms

Anxiety and obsessive-compulsive disorders are common childhood psychiatric disorders. Behavioral inhibition (BI) is a widely studied risk factor for anxiety. Less is known about overcontrol, a related behavioral phenotype characterized by concern for errors, perfectionism, and inflexibility and also associated with anxiety and obsessive-compulsive disorder. Both BI and overcontrol show associations with aberrant cognitive control and neural error responding (via the error-related negativity; ERN) yet it is unknown whether each imparts differential risk. Understanding whether overcontrol demonstrates independent associations from BI with cognitive functioning, neural error monitoring, and childhood anxiety and obsessive-compulsive presentations could aid in identifying a novel mechanistic treatment target. We assessed BI, overcontrol, cognitive functioning and psychopathology in a cross-sectional sample of 5-6 year old children (N = 126). Children completed an electroencephalogram (EEG) to assess the ERN. Overcontrol was associated with worse cognitive shifting, worse inhibitory control and higher anxiety and obsessive-compulsive symptoms, beyond BI. BI was associated with worse cognitive shifting, better inhibitory control and higher anxiety symptoms, beyond overcontrol. When assessed simultaneously, only overcontrol demonstrated a significant relationship with a blunted ERN. Moreover, overcontrol mediated (cross-sectionally) the well-established relationship between ERN and anxiety and obsessive-compulsive symptoms. BI and overcontrol impart differential risk for child cognitive functioning and anxiety while overcontrol demonstrates additional risk for aberrant neural error monitoring, anxiety and obsessive-compulsive presentations. Overcontrol may also be a mechanistic pathway between the ERN and transdiagnostic anxiety and obsessive-compulsive symptoms. Overcontrol may be a target warranted for early-childhood intervention in anxiety and OCD.

Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: study protocol for a scoping review

INTRODUCTION

Dialectical behaviour therapy (DBT) is a well-known intervention for treating borderline personality disorder, and has been increasingly adapted for other disorders. Standard DBT consists of four treatment modes, delivered over a year. Adaptations to DBT include changes to modes of delivery, treatment length, and skills modules taught to clients, or incorporating interventions from other evidence-based therapies. There is a need to synthesise existing evidence on DBT so that stakeholders-clinicians, researchers and policymakers-can understand how it has been provided for various psychiatric conditions, and whether it has been effective.

METHODS AND ANALYSIS

This study proposes a scoping review conducted according to Arksey and O'Malley's (2005) procedures, to map and summarise the literature on DBT interventions for treating a range of psychiatric concerns. Electronic databases (ie, the Cochrane Central Register of Controlled Trials, PubMed, PsycINFO, SCOPUS, EBSCOhost and ProQuest Dissertations and Theses), conference proceedings and the US National Institutes of Health Ongoing Trial Register will be searched for intervention studies that involve a control or comparison group, and that report quantitative data on pre/post-measures for psychiatric symptom severity. The initial search was conducted on 18 September 2020, and data charting has not commenced. An update will be performed in September 2022, pending this protocol's publication. Data charting will collect individual studies' characteristics, methodology and reported findings. Outcomes will be reported by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for Scoping Reviews.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. The goal of dissemination is to keep DBT stakeholders abreast on latest updates in clinical applications of DBT. Findings from this research are intended to inform a more specific topic of study (eg, a meta-analysis), to further aid in the development of DBT interventions for psychiatric populations.

REGISTRATION DETAILS

The study protocol was pre-registered with the Open Science Framework on 24 August 2021 (https://osf.io/vx6gw).

Attachment insecurity predicts worse outcome in patients with eating disorders treated with enhanced cognitive behavior therapy: A one-year follow-up study

OBJECTIVE

This study aimed to explore the role of attachment insecurity in predicting a worse longitudinal trend of eating disorder (ED) psychopathology and body uneasiness in patients with Anorexia Nervosa (AN) or Bulimia Nervosa (BN) treated with Enhanced Cognitive Behavior Therapy, considering the longitudinal interplay between these dimensions.

METHOD

In total, 185 patients with AN or BN performed the baseline assessment, and 123 were re-evaluated after 1 year of treatment. Participants completed questionnaires evaluating ED psychopathology (Eating Disorders Examination Questionnaire) and body uneasiness (body uneasiness test). For the assessment of adult attachment, the Experiences in Close Relationships-Revised was administered at baseline. Bivariate latent change score analysis within the structural equation modeling framework was performed to investigate the evolution of ED psychopathology and body uneasiness, their longitudinal interplay, and the role of attachment style as an outcome predictor.

RESULTS

After treatment, all psychopathological features showed an overall improvement. Higher baseline levels of body uneasiness predicted a worse course of ED psychopathology. The change in body uneasiness over time depended on changes over time in ED psychopathology, but not vice versa. Insecure attachment predicted a worse longitudinal trend of ED psychopathology, and, through this impairment, it indirectly maintained higher levels of body uneasiness, as confirmed by mediation analyses.

DISCUSSION

The role of attachment insecurity as a predictor of treatment outcome suggests the need for an integration of the cognitive-behavioral conceptualization of EDs with a developmental perspective that considers attachment-related issues.

PUBLIC SIGNIFICANCE STATEMENT

Considering the burden of EDs in terms of public health and the unsatisfactory response to standard treatments, the identification of outcome predictors is of considerable clinical interest. This study demonstrated that attachment insecurity was associated with worse longitudinal trends of ED psychopathology and body uneasiness in patients with AN and BN treated with CBT-E, highlighting the importance of personalizing treatment programs taking into account a developmental perspective on these disorders.

Adolescent experience of radically open dialectical behaviour therapy: a qualitative study

BACKGROUND

Radically Open Dialectical Behaviour Therapy (RO DBT) is a novel transdiagnostic treatment that targets 'maladaptive overcontrol'; a transdiagnostic cluster of traits associated with excessive emotional and behavioural inhibitory control. Outcomes are promising for adults with a range of psychiatric disorders. No study to date has explored the adolescent experience of RO DBT.

METHODS

Of the 25 eligible adolescents who received RO DBT between March 2015 and April 2017, 15 (14-17 years) consented and completed a semi-structured interview about their experience of treatment within 1 month of discharge. Interviews were recorded and then transcribed manually. Free text responses were analysed using reflexive thematic analysis.

RESULTS

The majority (n = 13) had a primary diagnosis of anorexia nervosa, although comorbidity was the norm, with 80.0% having two or more predicted comorbid psychiatric diagnoses. All had received some prior psychological treatment. Four themes were identified from analysis of transcripts: 1) Broadening Horizons, 2) Building Connections, 3) Flexibility, 4) Information Overload. Generally, RO DBT was perceived as helpful in both content and process. The focus on social and broader well-being, rather than specific mental health symptoms, was considered beneficial by many. Adolescents appreciated the group-based format of skills classes and reported benefiting from learning and practicing skills each week. The fourth theme, Information Overload, highlighted that for some, the amount of content felt overwhelming and that it was hard to remember and digest all the information, suggesting that adaptations, or simplifications, may be required to ensure accessibility for adolescents.

CONCLUSIONS

RO DBT is perceived as a relevant and beneficial new treatment for adolescents with maladaptive overcontrol. The broad treatment focus is perceived as unique and of particular benefit. It is reported to help with general and social functioning and foster cognitive and behavioural flexibility. Nevertheless, the amount and complexity of material was felt to be very large by some and may suggest the need for modified adolescent-specific materials.

The clinical effectiveness and cost-effectiveness of a 'stepping into day treatment' approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial

BACKGROUND

Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a 'step-down' treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation.

METHODS

386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m2 and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden.

DISCUSSION

The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision.

TRIAL REGISTRATION

ISRCTN ISRCTN10166784 . Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.

Concerns and recommendations for using Amazon MTurk for eating disorder research

OBJECTIVE

Our original aim was to validate and norm common eating disorder (ED) symptom measures in a large, representative community sample of transgender adults in the United States. We recruited via Amazon Mechanical Turk (MTurk), a popular online recruitment and data collection platform both within and outside of the ED field. We present an overview of our experience using MTurk.

METHOD

Recruitment began in Spring 2020; our original target N was 2,250 transgender adults stratified evenly across the United States. Measures included a demographics questionnaire, the Eating Disorder Examination-Questionnaire, and the Eating Attitudes Test-26. Consistent with current literature recommendations, we implemented a comprehensive set of attention and validity measures to reduce and identify bot responding, data farming, and participant misrepresentation.

RESULTS

Recommended validity and attention checks failed to identify the majority of likely invalid responses. Our collection of two similar ED measures, thorough weight history assessment, and gender identity experiences allowed us to examine response concordance and identify impossible and improbable responses, which revealed glaring discrepancies and invalid data. Furthermore, qualitative data (e.g., emails received from MTurk workers) raised concerns about economic conditions facing MTurk workers that could compel misrepresentation.

DISCUSSION

Our results strongly suggest most of our data were invalid, and call into question results of recently published MTurk studies. We assert that caution and rigor must be applied when using MTurk as a recruitment tool for ED research, and offer several suggestions for ED researchers to mitigate and identify invalid data.

Qualitative patient experiences from the Self-Blame and Perspective-Taking Intervention for eating disorders

BACKGROUND

Problems in social cognition and social support contribute to eating disorders (ED). Group therapy provides an ideal format to create an experiential learning environment focused on understanding social interactions. This pilot study examined the qualitative content of the participants' experiences in the Self-Blame and Perspective-Taking Intervention (SBPI) for ED.

METHODS

The SBPI was a 4-week group therapy intervention involving art therapy and psychoeducation that focused on social behaviors in ED patients. Participants received surveys immediately after the intervention and at 1 to 4 weeks after the post-intervention. Thematic analyses of qualitative feedback were performed using Braun and Clarke's thematic analysis framework.

RESULTS

Inductive analyses revealed three main themes: (1) Developing self-acceptance through emotional reflection, (2) Changing expectations with neurosocial knowledge, and (3) Bonding and vulnerability in social interactions; all concepts intentionally targeted by the SBPI. Participants varied in their support of a guideline to exclude personal discussion of ED-related cognitions and behaviors in the group.

CONCLUSIONS

As a whole, patients valued the combination of psychosocial education with group experientials focused on social behavior. Positive feedback from the SBPI suggests that adjunctive treatments that target mental-wellness constructs indirectly related to ED pathology may be helpful by allowing patients to see themselves as separable from the illness. Trial registration ClinicalTrials.gov, NCT0487758. Registered 7 May 2021-Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04877158 .

Smartphone application for adolescents with anorexia nervosa: an initial acceptability and user experience evaluation

BACKGROUND

Anorexia Nervosa (AN) is a key target for E-Health programs considering the many barriers hindering patients' access to care and the disorder's severity. Although these programs have become more common and effective, they often have low adherence, especially among youth. This can hinder their implementation and effectiveness in real-world settings. User experience partly overlaps with the acceptability field and may provide insight into factors affecting adherence and adoption of E-Health programs. This study aimed to explore early acceptability and user experience of a companion app prototype for adolescents with AN using user-centered design methods.

METHODS

We developed a prototype containing self-help material and emotions and behaviors evaluation and management features. Then we conducted a mixed evaluation combining semi structured focus group interviews and questionnaires in a clinician group and an AN patient group. We analyzed data using thematic analysis and descriptive statistics.

RESULTS

The app's overall appeal was adequate. The user experience questionnaire revealed the weakest dimensions, including novelty, dependability, and efficiency versus stimulation (i.e., ability to induce motivation to use the product) and perspicuity (i.e., easy to understand, to get familiar with). The qualitative data analysis revealed three central axes: acceptability, features, and use. We identified acceptability barriers and facilitators such as the importance of design and customization, especially for adolescents. Psychoeducation was a major feature for participants, as patients highlighted the difficulties they encountered when seeking disorders-related information.

CONCLUSIONS

This study shows the importance of including users in the different stages of an e-health intervention development, in order to identify their needs, general use and compliance patterns, to improve adherence and adoption of the program and its effectiveness.

Radically open dialectical behaviour therapy adapted for adolescents: a case series

BACKGROUND

Overcontrol is a transdiagnostic cluster of traits associated with excessive psychological, behavioural and social inhibitory control. It is associated with psychiatric diagnoses of depression, restrictive eating disorders and/or obsessive-compulsive personality disorder. Radically Open Dialectical Behaviour Therapy is a transdiagnostic treatment for maladaptive overcontrol. This case series evaluates an adolescent adaption (RO-A) for a transdiagnostic group of adolescents identified as overcontrolled.

METHODS

Twenty-eight adolescents were consecutively referred for RO-A from two different National and Specialist Child and Adolescent Mental Health Services between June 2017 and February 2020. Baseline self-report measures assessed overcontrol characteristics, relationship and attachment quality and mental health symptoms of depression and eating disorders, which were repeated at discharge.

RESULTS

Adolescents in this case series reported high rates of depression (78.6%), self-harm (64.3%) and eating disorders (78.6%). Most (85.7%) had two or more mental health diagnoses and all had previous mental health treatments before starting RO-A. The mean number of RO-A sessions attended was 18 group-based skills classes and 21 individual sessions over a mean period of 34 weeks. Significant improvements with medium and large effect sizes were reported in cognitive flexibility (d = 1.63), risk aversion (d = 1.17), increased reward processing (d = .79) and reduced suppression of emotional expression (d = .72). Adolescents also reported feeling less socially withdrawn (d = .97), more connected to others (d = 1.03), as well as more confident (d = 1.10) and comfortable (d = .85) in attachment relationships. Symptoms of depression (d = .71), eating disorders (d = 1.06) and rates of self-harm (V = .39) also significantly improved. Exploratory correlation analyses suggest improvements in overcontrol are moderately to strongly correlated with improvements in symptoms of depression and eating disorders.

CONCLUSIONS

This case series provides preliminary data that RO-A may be an effective new treatment for adolescents with overcontrol and moderate to severe mental health disorders like depression and eating disorders. RO-A led to improved management of overcontrol, improved relationship quality and reduced mental health symptoms. Further evaluation is indicated by this case series, particularly for underweight young people with eating disorders. More rigorous testing of the model is required as conclusions are only tentative due to the small sample size and methodological limitations.

Radically open dialectical behavior therapy for anorexia nervosa: A multiple baseline single-case experimental design study across 13 cases

BACKGROUND AND OBJECTIVES

No treatment for adult anorexia nervosa (AN) has shown sufficient effectiveness or superiority to other treatments. Overcontrol has been suggested as a viable mechanism to target in the treatment of patients with AN. Radically open dialectical behavior therapy (RO DBT) is developed for disorders related to maladaptive overcontrol. Our objective was to evaluate the outcome of RO DBT for AN in a clinical outpatient setting.

METHODS

Thirteen adult female patients with mild to moderate AN provided written consent and entered a multiple baseline single-case experimental design study. Median age at eating disorder (ED) onset was 15 years and the median duration of the ED was 10 years. Individual changes were assessed weekly during a baseline phase (A) of four to six weeks, and during the subsequent 40-week RO DBT phase (B). Additional assessments were conducted before and after treatment, and at a six-month follow-up. Primary outcome was ED psychopathology. Secondary outcomes were psychosocial impairment, quality of life, social connectedness, and adaptive control strategies.

RESULTS

Eight patients (62%) completed treatment. All completers were in full remission after treatment, with BMI ≥18.5 kg/m² and ED psychopathology within one standard deviation of the community mean. Improvements occurred after introducing RO DBT, not during baseline.

LIMITATIONS

Participants were female with mild to moderate AN, limiting generalizability to severe AN or males.

CONCLUSIONS

The study provides preliminary support for using RO DBT in adult outpatients with AN and overcontrol. Further studies should replicate these findings.

Evaluation of radically open dialectical behaviour therapy in an adult community mental health team: effectiveness in people with autism spectrum disorders

AIMS AND METHOD

Radically open dialectical behaviour therapy (RO DBT) is a transdiagnostic treatment designed to address disorders associated with overcontrol, including autism spectrum disorders (ASD). To date, no studies have reported on the effectiveness of RO DBT for people with ASD. Forty-eight patients were referred to a RO DBT programme, of whom 23 had a diagnosis of ASD. Outcome was measured using the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE) and the Questionnaire about the Process of Recovery.

RESULTS

The intervention was effective, with a medium effect size of 0.53 for improvement in CORE global distress. End-point CORE global distress score was predicted from initial severity and a diagnosis of ASD. Participants with a diagnosis of ASD who completed the therapy had significantly better outcomes than completing participants without an ASD diagnosis.

CLINICAL IMPLICATIONS

These findings provide preliminary support for RO DBT as an effective intervention for ASD in routine settings.

Updates in the treatment of eating disorders in 2020: a year in review in eating disorders: the journal of treatment & prevention

Several important studies advancing treatment of eating disorders were published in Eating Disorders: The Journal of Treatment & Prevention in 2020. This review summarizes the recent contributions to the literature on the treatment of eating disorders, including dialectical behavior therapy, yoga for positive embodiment, and treatment innovations in children and adolescents with eating disorders. Dialectical behavior therapy can be effectively used in complex eating disorder presentations, such as with comorbid substance use disorder and with suicidal behavior, and can be adapted for culturally-responsive treatments for binge eating and for guided self-help. Yoga may promote positive embodiment, which is supported by conceptual frameworks, studies evaluating yoga treatment interventions, and systematic reviews. Advances in eating disorder treatment for children and youth include the development of the Emotional Eating Scale adapted for children and adolescents, a review of primary care interventions for eating disorder treatment, and siblings' perspectives on eating disorder treatment. Research on novel methods including telementoring and innovative treatment modalities invoking feminism are promising areas of future research.

The costs of over-control in anorexia nervosa: evidence from fMRI and ecological momentary assessment

A growing body of evidence suggests that a high level of self-control may, despite its positive effects, influence cognitive processing in an unfavorable manner. However, the affective costs of self-control have only rarely been investigated. Anorexia nervosa (AN) is an eating disorder that is often characterized by excessive self-control. Here, we used fMRI to explore whether over-control in AN may have negative affective consequences. 36 predominantly adolescent female AN patients and 36 age-matched healthy controls (HC) viewed negative and neutral pictures during two separate fMRI sessions before and after 10 min of rest. We tested whether abnormally elevated neural activity during the initial presentation in a brain region broadly implicated in top-down control, the dorsolateral prefrontal cortex (dlPFC), could predict subsequent activation in limbic areas relevant to bottom-up affective processing. Using ecological momentary assessment (EMA), we also tested for associations between the aforementioned neuroimaging markers and negative affective states in the two weeks following the experiment. fMRI data revealed that higher initial activation of the dlPFC in AN predicted increased amygdala reactivity during the second fMRI session, which in turn was related to increased self-reported tension during two weeks following the scan. These data suggest that over-control in AN patients may come at a cost including negative affective states on a short (minutes) as well as a longer time scale (days). This mechanism may significantly contribute to the persistence of AN.

Influence of suppression and reappraisal on eating-related symptoms and ruminative thinking in anorexia nervosa and bulimia nervosa

The goal of the present study was to investigate the influence of expressive suppression and cognitive reappraisal on eating-related symptomatology in anorexia nervosa (AN) and bulimia nervosa (BN). Secondly, on the background of theoretical models proposing a reciprocal relationship between suppression and rumination, we sought to understand whether inhibition of emotional expression also affects ruminative thinking in eating disorders. Women with AN (n = 39), BN (n = 37) and a control group (CG, n = 41) were randomly assigned to either engage in suppression or reappraisal during a sadness-eliciting film clip. Levels of drive to eat, anticipated loss of control over eating and ruminative thoughts were rated before and after the induction of emotion regulation. Induced expressive suppression led to a decrease of reported drive to eat in AN and an increase of anticipated loss of control over eating in BN. All groups responded to suppression with greater rumination, whereas no significant changes were found for reappraisal. Mediation analyses on trait questionnaires pointed to rumination as a partial mediator of the correlation between suppression and eating disorder pathology. Results are discussed in line with recent empirical research and current emotion regulation theories.

Sharing and connecting with others - patient experiences of radically open dialectical behavior therapy for anorexia nervosa and overcontrol: a qualitative study

BACKGROUND

Recovery rates after psychological treatments for anorexia nervosa are low to moderate, and in adults, no treatment outperforms any other. The aim of this study was to evaluate patient experiences of Radically open dialectical behavior therapy (RO DBT), a treatment developed for disorders related to maladaptive overcontrol.

METHODS

Eleven female patients with anorexia nervosa were interviewed after either treatment completion (eight patients) or drop-out (three patients) from RO DBT. Interviews were transcribed and analyzed with inductive thematic analysis.

RESULTS

The analysis yielded five main themes: 1) a comprehensive treatment, 2) the benefits of sharing and connecting with others, 3) growing trust, 4) moving toward valued goals - but some remain, and 5) doing well in treatment.

CONCLUSION

Patients appreciated what they described as a comprehensive treatment and holistic view of their problems, which helped them reduce both maladaptive overcontrol and eating disorder symptoms. Gradually sharing personal experiences both in- and outside therapy was described as essential and led to enhanced social connectedness.

TRIAL REGISTRATION

The intervention study (Isaksson M, et al. J Behav Ther Exp Psychiatry. 71, 2021) that preceded this interview study was performed by the first, second, third, and fifth author, preregistered in the ISRCTN registry (no: ISRCTN47156042 ).

Current Therapeutic Approaches to Anorexia Nervosa: State of the Art

Anorexia nervosa (AN) is a devastating psychiatric disorder characterized by extreme restriction of food intake and low body weight, both associated with significant medical and psychological morbidity. The clinical severity of AN has prompted the consideration and study of behavioral and pharmacological treatments in efforts to establish empirically based methods to reduce the burden of the disorder. Among adolescents, family-based treatment is considered a first-line behavioral treatment. Research continues to explore the efficacy of family-based treatment and predictors of treatment response to further improve outcomes. Several behavioral treatments for adults also exist, including cognitive-behavioral therapy, exposure and response prevention, third-wave acceptance-based treatments, and supportive psychotherapy, all of which help to improve symptoms and promote modest weight gain. Despite this, no one treatment is considered superior, and all existing behavioral approaches leave a proportion of adults symptomatic or at a high risk of relapse. As such, among adults, there is continued need for development of novel, mechanism-based approaches to better target the core symptoms of AN. Although antidepressants impart little benefit on weight or symptoms, the second-generation antipsychotic olanzapine has shown ability to promote modest weight gain in outpatients with AN. Most recently, the field's evolving conceptualization of AN as a biologically based disorder coupled with technological advancements has led to consideration of varying neuromodulation strategies as a potential therapeutic approach that remains under investigation.

REMOTION Blended Transdiagnostic Intervention for Symptom Reduction and Improvement of Emotion Regulation in an Outpatient Psychotherapeutic Setting: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Emotion regulation has been identified as an important transdiagnostic factor relevant to the treatment of mental health disorders. Many empirically validated psychotherapeutic treatments incorporate elements targeting emotion regulation. Most of these treatment approaches are conceptualized as standard face-to-face treatments not as blended treatments, which include an internet-based intervention.

OBJECTIVE

The aim of this study is to examine, for the first time, a new internet-based intervention-REMOTION-that will be provided transdiagnostically, as an add-on to psychotherapy, to provide a blended treatment format.

METHODS

A total of 70 participants will be assigned (1:1 allocation ratio) to either the intervention group (REMOTION + psychotherapy) or the treatment-as-usual group that receives psychotherapy alone. To maximize external validity, a typical outpatient treatment sample of patients diagnosed with a range of disorders such as depression, anxiety disorders, and adjustment disorder will be recruited from a university outpatient clinic. Patients with bipolar disorder, psychotic disorders, or acute suicidality will be excluded from the study. The feasibility and potential effectiveness of the intervention will be examined by assessing data at baseline, 6 weeks (post), and 12 weeks (follow-up). The primary outcome is general symptom severity, assessed with the Brief Symptom Inventory. Secondary outcomes are emotion regulation, depressive symptoms, anxiety symptoms, health related quality of life, well-being, and a variety of feasibility parameters. Quantitative data will be analyzed on an intention-to-treat basis.

RESULTS

Participant recruitment and data collection started in February 2020, and as of November 2020, are ongoing. Results for the study are expected in 2022.

CONCLUSIONS

This pilot randomized controlled trial will inform future studies using transdiagnostic blended treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04262726; http://clinicaltrials.gov/ct2/show/NCT04262726.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/20936.

Impulsivity and compulsivity in anorexia and bulimia nervosa: A systematic review

This study aimed to systematically appraise cross-sectional research that compared the cognitive performance of individuals in the acute phase of BN and/or AN to HCs on measures of impulsivity and compulsivity. The results of the systematic review showed support for the trans-diagnostic approach to eating disorders. There was no strong evidence to support the characterisation of AN as high in compulsivity (and low in impulsivity), nor to support the characterisation of BN as high in impulsivity (and low in compulsivity). There appeared to be mixed findings for both impulsivity and compulsivity across AN and BN. Results were highly variable due to the heterogeneous tasks used, and lack of replication across studies. There was no consensus amongst the included studies on the most appropriate task and/or outcome measures that should be used to study the constructs of impulsivity and compulsivity.

The autism diagnostic observation schedule: Patterns in individuals with anorexia nervosa

OBJECTIVE

Studies have used the Autism Diagnostic Observation Schedule (the ADOS-2) in individuals with anorexia nervosa (AN), but the patterns of scores have not been assessed. We examined which subset of the ADOS-2 items best discriminate individuals with AN from healthy controls (HC), and assessed the potential clustering of AN participants based on different profiles of the ADOS-2 item scores.

METHOD

We combined datasets from two previous studies, and (a) compared mean ranks between young AN participants (N = 118) and HC (N = 42), (ii) replicated the item selection procedure of the existing ADOS-2 algorithm to assess sensitivity of items in the AN group, and (c) applied a two-step clustering analysis in the AN group (N = 149).

RESULTS

AN participants displayed significantly higher mean ranks than HC participants in five of 32 items. All five items are part of the existing ADOS-2 algorithm. We found two clusters of AN participants; one representing normal social behaviour, comprising 68% of the individuals with AN, and one representing less efficient social behaviour, comprising 32% of individuals with AN.

CONCLUSIONS

The items comprising the social affective cluster of the existing ADOS-2 algorithm are well suited to assess difficulties with social functioning in individuals with AN.

Suicide attempts requiring hospitalization in patients with eating disorders: A retrospective cohort study

OBJECTIVE

Suicide attempts requiring hospitalization are known to be common in patients who are diagnosed with eating disorders. Attempting suicide is a major indicator for those at risk of completed suicide. Both the specific eating disorder diagnosis and the influence of psychiatric comorbidities on suicide attempts requiring hospitalization were investigated, with demographic and socioeconomic variables as confounders, over a 10-year observation period from January 2007 to March 2017.

METHODS

Anonymized health-record data from the South London and Maudsley NHS Foundation Trust (SLaM) were retrieved through the Clinical Record Interactive Search (CRIS) data resource; this is linked to national Hospital Episode Statistics (HES) data. These data include all diagnoses for inpatient admissions. Hazard ratios, with 95% confidence intervals (CIs), were calculated from cox regression analyses and the effects of a number of confounders were estimated by performing multivariable analyses.

RESULTS

In total, 4,895 patients were diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder otherwise not specified (EDNOS). Of these, 331 (6.7%) had attempted suicide requiring hospitalization and 21 (0.04%) completed suicide. The eating disorder category associated with the highest risk of a suicide attempt was AN (HR: 1.43, 95%CI: 1.08-1.89, p = .01). The risk was significantly increased further if the patient had a comorbid diagnosis of personality disorder, depression, bipolar affective disorder, and substance misuse.

DISCUSSION

Suicide attempts requiring hospitalization have a high incidence rate among patients with eating disorders, and the risk is significantly increased in AN. Comorbid psychiatric illness and suicidal ideation should be carefully assessed in all eating disorder patients.

Emotion Regulation Difficulties During and After Partial Hospitalization Treatment Across Eating Disorders

Emotion regulation deficits are associated with eating disorder (ED) symptoms, regardless of eating disorder diagnosis. Thus, recent treatment approaches for EDs, such as dialectical behavior therapy (DBT), have focused on teaching patients skills to better regulate emotions. The present study examined changes in emotion regulation among adult patients with EDs during DBT-oriented partial hospital treatment, and at follow-up (M[SD] = 309.58[144.59] days from discharge). Exploratory analyses examined associations between changes in emotion regulation and ED symptoms. Patients with anorexia nervosa, restricting (AN-R, n = 77), and binge-eating/purging subtype (AN-BP, n = 46), or bulimia nervosa (BN, n = 118) completed the Difficulties in Emotion Regulation Scale (DERS) at admission, discharge, and follow-up. Patients with BN demonstrated significant improvements across all facets of emotion dysregulation from admission to discharge and maintained improvements at follow-up. Although patients with AN-BP demonstrated statistically significant improvements on overall emotion regulation, impulsivity, and acceptance, awareness, and clarity of emotions, from admission to discharge, these improvements were not significant at follow-up. Patients with AN-R demonstrated statistically significant improvements on overall emotion dysregulation from treatment admission to discharge. Changes in emotion regulation were moderately correlated with changes in ED symptoms over time. Results support different trajectories of emotion regulation symptom change in DBT-oriented partial hospital treatment across ED diagnoses, with patients with BN demonstrating the most consistent significant improvements.

Refractory depression - mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms

BACKGROUND

Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression.

AIMS

To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627).

METHOD

RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated.

RESULTS

After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94-9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI -2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI -2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group.

CONCLUSIONS

The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.

Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions

Over the past several decades, Dialectical Behavior Therapy (DBT) has been adapted for a range of presenting problems related to emotion dysregulation. Considerable enthusiasm exists regarding the use of DBT for treating eating disorders; however, to date, there have been no reviews summarizing empirical efforts to adapt DBT for eating disorders in youth. Accordingly, in the present narrative review, we provide a comprehensive summary of existing work testing DBT for adolescent eating disorders. First, we briefly review existing work applying DBT to eating disorders in adults and general adolescent samples. We then review research focused specifically on the use of DBT for adolescent eating disorders, including both those studies applying DBT as the primary treatment and investigations of DBT as an adjunctive treatment. Overall, initial results for DBT-based approaches are promising. However, rigorous empirical work testing DBT for treating adolescent eating disorders remains limited; the majority of existing research is comprised of case series and small-scale studies. Therefore, we close with specific recommendations for future research testing this approach.

Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders

Despite the effectiveness of CBT in reducing shape/weight concerns and dietary restraint, research suggests that patients considered recovered may still exhibit emotional difficulties related to eating disorders (EDs). Dialectical behavior therapy (DBT) has been adapted for a variety of mental disorders characterized by emotion dysregulation and, more recently, for EDs specifically. The current review found that the majority of the research studies employed one of the following three adaptations of DBT for EDs: The Stanford Model, Radically Open-DBT (RO-DBT), or Multidiagnostic ED-DBT (MED-DBT). Therefore, this review sought to review and update the empirical research on each adaptation and (2) offer preliminary recommendations for when and which adaptation of DBT to use when treating adults with EDs. Findings from the empirical literature on DBT and EDs indicate that the Stanford Model has the most rigorous and numerous studies demonstrating efficacy and effectiveness in those diagnosed with binge eating disorder. Fewer studies have been conducted using the Stanford Model with bulimia nervosa; therefore, less strong assertions can be made about DBT with those diagnosed with bulimia. The MED-DBT model has been evaluated in several open trials within higher levels of care with promising results, but the lack of randomized clinically-controlled trials prevents a definitive statement about its efficacy. Finally, research on applying the RO-DBT model to anorexia-nervosa, restricting subtype is in its infancy, prohibiting solid conclusions or recommendations regarding its efficacy or effectiveness.

Treatment of personality pathology through the lens of the hierarchical taxonomy of psychopathology: Developing a research agenda

Despite the emphasis on evidence-based treatment for psychological disorders, to date, there has been limited research examining treatment for nine of the 10 categorical personality disorders in DSM-5 Section 2. This is perhaps not surprising given the complex heterogeneity and co-morbidity within personality pathology. The hierarchical taxonomy of psychopathology (HiTOP) was proposed to address limitations within the traditional categorical model of the diagnostic system. Within this system are five spectra: detachment, antagonistic externalizing, disinhibited externalizing, thought disorder and internalizing. These foundational personality traits potentially have direct and specific treatment implications. The purpose of this paper is to highlight potential psychotherapeutic and pharmacological treatment recommendations within the personality spectra. Additionally, we outline the advantages of considering the personality science found within dimensional models of psychopathology in clinical assessment and intervention to aid in treatment planning. © 2019 John Wiley & Sons, Ltd.

Radically Open Dialectical Behavior Therapy: Social Signaling, Transdiagnostic Utility and Current Evidence

At the core of an overcontrolled personality and coping style is a tendency to have too much self-control, exhibiting as behavioral and cognitive inflexibility, high inhibition of emotion, high detail-focused processing and perfectionism, and a lack of social connectedness. Overcontrol underlies a wide variety of psychiatric illnesses and as such, an innovative transdiagnostic therapy called Radically Open Dialectical Behavior Therapy (RO DBT) has been developed to treat disorders characterized by overcontrol. RO DBT targets maladaptive social signaling in order to help individuals "rejoin the tribe," hypothesizing that increasing social connectedness by means of targeting social signaling is the central mechanism of change in treatment. Because RO DBT is used for individuals with an overcontrolled personality style, rather than individual disordered symptoms, it can be used transdiagnostically across a range of comorbid disorders, including treatment-resistant depression and anxiety, anorexia nervosa, and personality disorders such as obsessive-compulsive personality disorder. The current article introduces this novel treatment approach and discusses its emphasis on social signaling and its transdiagnostic nature. We then provide the first review of existing literature testing the efficacy of RO DBT across clinical populations, discuss issues related to assessment of overcontrol, and speculate on future directions for this novel therapy.

Task-switching inefficiencies in currently ill, but not remitted anorexia nervosa

OBJECTIVE

Models of anorexia nervosa (AN) posit that set-shifting deficits may contribute to behavioral inflexibility and extreme dietary restriction. Findings from neurocognitive studies of set-shifting in AN have been somewhat mixed, perhaps due to the use of tasks that cannot distinguish shifting from other processes (i.e., learning). To more precisely characterize cognitive flexibility and selectively assess this process independent of rule learning and feedback sensitivity, we examined task-switching ability in AN.

METHOD

Women ill with AN, subthreshold AN or atypical AN (IAN; n = 40), women remitted from AN (RAN; n = 24), and age-matched healthy control women (n = 42) completed a computerized cued color-shape task-switching paradigm. Groups were compared on mix costs (reflecting global cognitive control) and switch costs (reflecting transient cognitive control).

RESULTS

Although mix costs were equivalent across groups, switch costs were more pronounced in the IAN group, as indicated by a group-by-trial type interaction for reaction times on stay and switch trials.

DISCUSSION

Findings indicate that IAN, but not RAN, have difficulty flexibly switching between cognitive task sets, and suggest that prior findings of set-shifting deficits in AN may reflect difficulty with cognitive flexibility independent of learning deficits. As such, task-switching may represent a promising adjunctive treatment target.

Capturing the impact of adolescent inpatient admissions: The Social Connectedness Scale

BACKGROUND

Outcome measurement is central to health service provision. In child and adolescent mental health services (CAMHS), there are established tools used to assess symptoms and track progress. However, there is a relative dearth of assessments of subjective well-being or recovery. Social connectedness is a concept linked with well-being and risk in young people. We sought to evaluate the utility and acceptability of a measure of social connectedness in inpatient CAMHS.

METHOD

As part of routine clinical practice, we asked 92 young people (mean age 16 years old) on two inpatient CAMHS wards to complete the Social Connectedness Scale, alongside other assessments, and also comment on its acceptability. We repeated the measure on discharge from the unit.

RESULTS

The findings showed that the measure was internally consistent (α = .910) and sensitive to change in this population. Scores also correlated with another self-report measure focusing on well-being and mental distress, but not with clinician-rated measures. Ratings of relevance and ease of understanding were reasonable and young people value social connection.

CONCLUSION

The Social Connectedness Scale might offer an appropriate method of exploring this element of young peoples' experience and progress, as part of inpatient mental health admissions.

Emerging Psychological Treatments in Eating Disorders

The authors present the theoretic model, structure of treatment, and preliminary evidence for several emerging treatments that are increasingly being used and studied in eating disorders treatment, including dialectical behavior therapy, acceptance and commitment therapy, integrative cognitive-affective therapy, and neuromodulation. In addition, the article discusses treatments that address mindfulness, interpersonal factors, and habit.

Acceptance and psychological change at the higher levels of care: A naturalistic outcome study

This naturalistic outcome study reports on psychological change among a large (N = 617), transdiagnostic sample of eating disordered adults treated at higher levels of care at a private facility. Patients were assessed at admission and discharge for eating disorder psychopathology, depression, personality, and acceptance. Effect sizes ranged from d = .29 to d = 1.29, and the majority of participants (58.2%) were treatment responders, with BN patients showing a higher response rate than AN-R patients. Increased acceptance over the course of treatment was strongly associated with decreased eating disorder risk and may be an important factor in recovery.

Advances in the treatment of anorexia nervosa: a review of established and emerging interventions

BACKGROUND

Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments.

METHODS

We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials.

RESULTS

We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation.

CONCLUSIONS

Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.

The real-life costs of emotion regulation in anorexia nervosa: a combined ecological momentary assessment and fMRI study

Regulation of emotions is necessary for successful attainment of short-term and long-term goals. However, over-regulation may also have its costs. In anorexia nervosa (AN), forgoing food intake despite emaciation and endocrine signals that promote eating is an example of "too much" self-control. Here we investigated whether voluntary emotion regulation in AN patients comes with associated disorder-relevant costs. Thirty-five patients with acute AN and thirty-five age-matched healthy controls (HCs) performed an established emotion regulation paradigm during functional magnetic resonance imaging after an overnight fast. The task required reducing emotions induced by positively valenced pictures via distancing. We calculated a neural regulation score from responses recorded in a reward-related brain region of interest (ventral striatum; VS) by subtracting activation measured on "positive distance" trials from that elicited under the "positive watch" (baseline) condition. Complementing the imaging data, we used ecological momentary assessment (EMA) to probe disorder-related rumination and affect six times/day for 2 weeks following the scanning session. The neural regulation score indicating reduced VS activation during emotion regulation was used as a predictor in hierarchical linear models with EMA measures as outcomes. No group differences in neural activity were found for the main contrasts of the task. However, regulation of VS activity was associated with increased body-related rumination and increased negative affect in AN, but not in HC. In line with this finding, correlational analysis with longitudinal BMI measurements revealed a link between greater VS regulation and poorer treatment outcome after 60 and 90 days. Together, these results identify a neural correlate of altered emotion regulation in AN, which seems to be detrimental to psychological well-being and may interfere with recovery.

Delay Discounting of Reward and Impulsivity in Eating Disorders: From Anorexia Nervosa to Binge Eating Disorder

Evidence points to eating disorder patients displaying altered rates of delay discounting (one's degree of preference for immediate rewards over larger delayed rewards). Anorexia nervosa (AN) patients are believed to have an increased capacity to delay reward, which reflects their ability to override the drive to eat. Contrarily, binge eating disorder (BED) patients are associated with a reduced predisposition to delay gratification. Here, we investigated monetary delay discounting and impulsivity in 80 adult women with EDs (56 AN and 24 BED), diagnosed according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, and 80 healthy controls. AN-restrictive (AN-R) subtype patients showed less steep discounting rates than BED and AN-bingeing/purging subtype patients. Compared with healthy controls and AN-R patients, BED and AN-bingeing/purging patients presented higher delay discounting and positive and negative urgency levels. Our findings suggest that restriction in AN-R patients is associated with disproportionate self-control, whereas bingeing behaviours could be more driven by emotional states and impulsivity traits. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Radically open DBT: Targeting emotional loneliness in Anorexia Nervosa

This article conceptualizes Anorexia Nervosa (AN) as a prototypical overcontrolled disorder, characterized by low receptivity and openness, low flexible control, pervasive inhibited emotional expressiveness, low emotional awareness, and low social connectedness and intimacy with others. As a result, individuals with AN often report high levels of emotional loneliness. A new evidence-based treatment, Radically Open Dialectical Behavior Therapy (RO-DBT), and its underlying neuroregulatory theory, offer a novel way of understanding how self-starvation and social signaling deficits are used as maladaptive regulation strategies to reduce negative affect. RO-DBT proposes that rather than trying to be 'emotionally regulated' or achieving equanimity, long-term psychological well-being is achieved by increasing social connectedness. RO-DBT skills, including body posture, gestures, and facial expressions, activate brain regions that increase social safety responses that function to automatically enhance the open-minded and flexible social-signaling, which are crucial for establishing long-term intimate bonds with others and becoming part of a "tribe."

Premorbid and Illness-related Social Difficulties in Eating Disorders: An Overview of the Literature and Treatment Developments

BACKGROUND

Social difficulties in eating disorders can manifest as predisposing traits and premorbid difficulties, and/or as consequences of the illness.

OBJECTIVE

The aim of this paper is to briefly review the evidence of social problems in people with eating disorders and to consider the literature on treatments that target these features.

METHOD

A narrative review of the literature was conducted.

RESULTS

People with eating disorders often manifest traits, such as shyness, increased tendency to submissiveness and social comparison, and problems with peer relationships before illness onset. Further social difficulties occur as the illness develops, including impaired social cognition and increased threat sensitivity. All relationships with family, peers and therapists are compromised by these effects. Thus, social difficulties are both risk and maintaining factors of eating disorders and are suitable targets for interventions. Several forms of generic treatments (e.g. interpersonal psychotherapy, cognitive analytic therapy, focal psychodynamic therapy) have an interpersonal focus and show some efficacy. Guided self-management based on the cognitive interpersonal model of the illness directed to both individuals and support persons has been found to improve outcomes for all parties. Adjunctive treatments that focus on specific social difficulties, such as cognitive remediation and emotion skills training and cognitive bias modification have been shown to have a promising role.

CONCLUSION

More work is needed to establish whether these approaches can improve on the rather disappointing outcomes that are attained by currently used treatments for eating disorders.

Therapists' self-reported drift from dialectical behavior therapy techniques for eating disorders

OBJECTIVE

Research has shown that clinicians underuse or omit techniques that constitute an essential part of evidence-based therapies. However, it is not known whether this is the case in DBT for eating disorders. The aims of this study were; 1) exploring the extent to which DBT techniques were used by self-identified DBT clinicians treating eating disorders; 2) determining whether therapists fell into distinct groups, based on their usage of DBT techniques; and 3) examining whether clinician characteristics were related to the use of such techniques.

METHOD

Seventy-three clinicians offering DBT for eating disorders completed an online survey about their use of specific DBT techniques. They also completed measures of personality and intolerance of uncertainty.

RESULTS

In relation to the first aim, the pattern of use of DBT techniques showed a bimodal distribution - most were used either a lot or a little. Considering the second aim, clinicians fell into two groups according to the techniques that they delivered - one characterized by a higher use of DBT techniques and the other by a higher use of techniques that were specific to the treatment of eating disorders, rather than DBT methods. Finally, more experienced clinicians were more likely to be in the 'DBT technique-focused' group.

DISCUSSION

DBT clinicians are encouraged to implement both sets of techniques (DBT techniques and standard techniques for the treatment of eating disorders) in an integrated way. Training, supervision and the use of manuals are recommended to decrease therapist drift in DBT.

Impairment of Social Function in Young Females With Recent-Onset Anorexia Nervosa and Recovered Individuals

PURPOSE

A subgroup of individuals with anorexia nervosa (AN) displays social difficulties; however, it is not clear if individuals with comorbid autism spectrum disorders account for these difficulties.

METHODS

We compared social function using the Autism Diagnostic Observation Schedule in 43 young females with first-episode AN who did not have comorbid autism spectrum disorder, 28 individuals recovered from adolescent-onset AN, and 41 healthy comparison individuals (age range 14-22 years). We measured adaptive behavior with the Vineland-II parent questionnaire, and aspects of social cognition with psychological tests, such as the Reading-the-Mind-in-the-Eyes test, Profile of Nonverbal Sensitivity short version, The Awareness of Social Inference Test, Animated Triangles, and the CANTAB Affective Go/No-go task.

RESULTS

Participants with first-episode AN and those recovered from AN displayed difficulties in social function, which were not associated with body mass index or other state factors of the disorder in those with first-episode AN. Mood problems and anxiety were not associated with these difficulties. Parents rated participants with first-episode AN lower than recovered and control participants on the Socialization Domain of Vineland-II. Finally, only participants recovered from AN demonstrated deficits in specific domains of social cognition: perceiving nonverbal bodily gesture and vocal prosody.

CONCLUSIONS

Young females with first-episode AN and those recovered from AN displayed impairments in social function, which may represent more stable traits of the disorder. Only participants recovered from AN demonstrated deficits in social cognition.

Trajectories of higher- and lower-order dimensions of negative and positive affect relative to restrictive eating in anorexia nervosa

Despite robust support for the role of affect in the maintenance of binge eating and purging, the relationship between affect and restrictive eating remains poorly understood. To investigate the relationship between restrictive eating and affect, ecological momentary assessment data from 118 women with anorexia nervosa (AN) were used to examine trajectories of higher-order dimensions of negative affect (NA) and positive affect (PA), as well as lower-order dimensions of NA (Fear, Guilt) and PA (Joviality, Self-Assurance) relative to restrictive eating. Affect trajectories were modeled before and after restrictive eating episodes and AN subtype was examined as a moderator of these trajectories. Across the sample, Guilt significantly increased before and decreased after restrictive eating episodes. Global NA, Global PA, Fear, Joviality, and Self-Assurance did not vary relative to restrictive eating episodes across the sample. However, significant subtype by trajectory interactions were detected for PA indices. Among individuals with AN restricting subtype, Global PA, Joviality, and Self-Assurance decreased prior to and Self-Assurance increased following restrictive eating episodes. In contrast, Global PA and Self-Assurance increased prior to, but did not change following, restrictive eating episodes among individuals with AN binge eating/purging subtype. Results suggest that dietary restriction may function to mitigate guilt across AN subtypes and to enhance self-assurance among individuals with AN restricting subtype. (PsycINFO Database Record